Arthur’s Quick & Dirty Pre-read

Table 75.6 Basic management essentials •Keep patient alive (maintain airway and circulation)•Get history from witnesses•Examine patient•Give ‘coma cocktail’ (TONG – thiamine, O2, naloxone, glucose)•Take blood (for investigations)•CT scan (if diagnosis doubtful)

Murtagh Table 75.6 Basic management essentials

The Unconscious Patient - Murtagh Practice tips

• The hypotensive patient is bleeding until proved otherwise.

• The presence of a head injury should not prevent rigorous resuscitation of the hypotensive patient.

• Always suspect cervical injury in the presence of patients who are victims of time-critical trauma.

• Tachypnoea is a sign of inadequate oxygenation and not a sign of central nerve damage.

• Always suspect opioid overdosage in the ‘unknown’ patient brought in with an altered conscious state.

• Consider administration of TONG - the ‘coma cocktail’.

Amphetamine Use (Jacobson: Psychiatric Secrets)

• Amphetamine use is highest among 18–25 year olds• Dependence: Animals will self-administer stimulants

continuously until they die, forsaking food and water and suffering repeated seizures and exhaustion; for many humans, similar effects have been seen.

• Amphetamine is available in oral prescription medication as dextroamphetamine and methamphetamine; it also is manufactured illicitly as powder or crystallized (“ice”) methamphetamine.

• MDMA (3,4-Methylenedioxymethamphetamine) – colloquially known as ecstasy

• MDMA induces euphoria, intimacy and diminishes anxiety

Signs of Amphetamine Intoxication

• Enlarged pupils, tachycardia, hypertension, and hyperreflexia. • The user feels euphoric, energetic, talkative, alert, and

grandiose, with decreased appetite and need for sleep. Some people, however, feel anxious, agitated, tense, and dysphoric. Still others feel calmed, slowed down, and focused.

• Stomach cramps, nausea, vomiting, and diarrhea may occur. Many users clench and grind their teeth.

• Higher doses and more chronic use frequently lead to psychosis, usually with a paranoid quality. Reactions may range from “tweaking,” a sense of hypervigilance and fearfulness (small noises may be interpreted as police outside the door), to overt psychosis with auditory and visual hallucinations, ideas of reference, and full-blown delusions.

Complications & Overdose

• Cerebral and renal vasculitis can occur with chronic use.

• Death from OD may occur from seizures, severe fever, cerebrovascular haemorrhage, or cardiovascular arrest.

• Treatment of overdose is supportive; seizures respond to diazepam, and psychosis may require antipsychotic medication.

Comorbidities

• Symptoms of psychiatric disorders such as depression, anxiety and bipolar and schizophrenia and schizoaffective disporders are common in patients misusing drugs and/or alcohol.

• Psychiatric disorders increase the risk of substance misuse.

• The key issue is to recognize that substance misuse may be contributing to their psychiatric problems.

Comorbidities – from Jacobson Psychiatric Secrets

• Patients with a dual diagnosis have higher morbidity, lower likelihood for initial treatment success, higher relapse rates, increased rates of hospitalization, and decreased adherence to treatment.

• They also are at increased risk for suicide.• The presence of substance abuse makes

diagnosis of both disorders more complicated.

Associated Psychiatric SymptomsSUBSTANCE PSYCHIATRIC SYMPTOMS DURING

INTOXICATIONPSYCHIATRIC SYMPTOMS DURING WITHDRAWAL

AlcoholAnxiety, depression, sudden mood changes, paranoia, suicidality, memory loss

Hallucinations (delirium tremens, alcohol hallucinosis) anxiety, insomnia, psychomotor agitation

Cocaine Mania, acute paranoid ideation, panic attacks Depression, anhedonia, anxiety

Stimulants Mania, paranoia, nightmaresDysphoria, psychomotor retardation, irritability, guilt, suicidality

Inhalants Anxiety, personality changes Anxiety, depressionCannabis Anxiety, paranoid ideation, suicidalityOpioids Panic reactions, lethargy Depression

Depressants Depression, anxiety, paranoia, psychosis

Insomnia, irritability, psychomotor agitation

Hallucinogens Hallucinations, paranoia, depersonalization, confusion

Flashbacks (may occur years after last use)

Psychiatric Symptoms Associated with Substance Abuse

Do certain psychiatric conditions tend to be seen with substance abuse?

• Yes. Antisocial personality disorder is highly correlated with substance abuse.

• In one extensive study, 84% of individuals with antisocial personality disorder also had a history of substance abuse.

• Mood disorders also are commonly associated with substance abuse; in the same study, 32% of individuals with a diagnosis of mood disorder were substance abusers.

• In addition, specific psychiatric disorders are associated with specific drugs of abuse, such as bipolar disorder with alcohol and panic disorder with sedatives and hypnotics.

Assessment• It is important to distinguish between substance-induced and

substance-related psychiatric disorders.• How can I tell whether a patient’s psychiatric symptoms are caused

by substance abuse? Timing, timing, timing! It is crucial to assess mental illness only after a period of abstinence, so that diagnosis is not confounded by drug intoxication mimicking psychiatric symptoms

• Generally it is recommended that the patient be drug-free for 2–4 weeks. A good history, from both the patient and family members, is crucial to understanding the clinical picture. A good history or prior familiarity with the patient also can help sort out confusing symptoms and make quicker diagnoses.

• Perform urinalysis and blood tests (e.g. to detect liver dysfunction secondary to alcohol or hepatitis)

History

• A comprehensive history including age of onset of disorders, chronology, persistence of psychiatric illness during abstinence, and family history should help determine whether an additional diagnosis to their substance misuse is present.

• In addition, the safety of prescribing a particular medication must be determined not only with regard to drug–drug interactions, but also with respect to how the medication is delivered or monitored

• considering particularly deliberate self-harm behaviour.

Is psychotherapy helpful in treating patients with a dual diagnosis?

• Psychotherapy, particularly supportive-expressive or cognitive-behavioral models, has been shown to be useful in treating patients with substance use disorders and psychiatric illness.

• Patients with comorbid mood and anxiety disorders tend to benefit from psychotherapy more than patients with personality disorders.

• In general, psychotherapy provides support for continued abstinence as well as adherence to medication regimens. It also addresses underlying emotional states, such as depression or anxiety, that may contribute to the maintenance of substance abuse.